Nocturnal Dipping Pattern Research Articles

Evaluation of renal functional reserve in patients with preserved renal function and coronary microvascular disease

Abstract Background/introduction Renal Functional Reserve (RFR) stands as a subject of significant scientific discussion,holding promise as a diagnostic tool for early detection of subclinical renal disorders. Literature establishes a link between chronic kidney disease & cardiovascular disease (CVD). Purpose This study aims to assess RFR in patients with coronary microvascular dysfunction (CMD), while maintaining preserved renal function (eGFR≥60ml/min/1.73m2 by CKD-EPI criteria)&proteinuria<400mg/24hr. The investigation seeks to provide insights into the nuanced relationship between renal function&CMD, offering potential early indicators of CVD. Methods This is a single-center, prospective study enrolling patients with CMD. In the absence of significant coronary artery disease, functional coronary circulation assessment was performed. Coronary flow reserve (CFR) & index of microvascular resistance (IMR) were measured invasively with bolus thermodilution technique. In all participants, RFR was estimated by endogenous creatinine clearance after oral protein load (cooked meal, 1.2gr/kg). Normal RFR was defined as≥30 ml/min/1.73m2. Also, patients with CMD were offered 24-hour Ambulatory Blood Pressure Monitoring (ABPM). Results A total of 25 participants have been enrolled so far in study: 11 without CMD - control group [7 female, 64%, mean age: 52.9±8.8 years) & 14 with CMD – CMD group (11 female, 79%, mean age: 53.5±10,3 years). CMD patients were classified into 2 groups, structural & functional endotype (CFR<2.5 & IMR≥25 were considered abnormal). The RFR value for CMD & control group is 7.4±6.3 vs 36.3±5.8 ml/min/1.73m2 respectively (p<0.05). This difference between groups remained statistically significant after controlling for confounding factors. It was found that RFR value for functional & structural CMD endotype was 3.8±2.6 & 9.6±7,2 ml/min/1.73m2 respectively (p=0.06). Furthermore, no statistical significance was found between RFR and IMR, CFR indices. According to data from ABPM, there were no significant differences in ambulatory blood pressure (both systolic and diastolic) between the two endotypes of CMD, as well as no relationship with RFR was observed. However, the proportion of non-dipping BP pattern was significantly higher in functional CMD endotype (p<0.05). It was not found correlation between RFR & non-dipping phenotype. Conclusions Impaired RFR is evident across all individuals experiencing microvascular angina. Furthermore, those with functional CMD exhibit a diminished RFR when compared with their counterparts with structural CMD. RFR does not exhibit a correlation with blood pressure levels or the absence of a nocturnal dipping pattern. In light of the hypothesis asserting that appraising renal functional reserve serves as an early diagnostic measure for subclinical renal disorders, promptly recognizing individuals with distinct phenotypes could facilitate tailoring therapeutic interventions on an individual basis.Functional Coronary AngiogramCMD group baseline characteristics

Reproducibility of daytime hypertension, night-time hypertension, and nocturnal blood pressure dipping patterns in young to middle age patients with stage 1 hypertension.

To investigate the reproducibility of ambulatory BP sub-periods and nocturnal dipping phenotypes assessed twice 3 months apart in young-to-middle-age untreated individuals screened for stage 1 hypertension. We investigated 1096, 18-to-45-year old participants from the HARVEST. Their office BP was 145.8 ± 10.4/93.7 ± 5.7 mmHg. Office BP and 24 h BP were measured at baseline and after 3 months. Office, 24-h, daytime and night-time hypertensions, and nocturnal dipping patterns were defined according to the 2023 ESH guidelines. Between-recording agreement was evaluated with kappa statistics. Reproducibility evaluated with weighted kappa was moderate for both 24 h hypertension (K = 0.48) and daytime hypertension (K = 0.50) and was only fair for night-time hypertension (K = 0.36). Between-measurement agreement was even worse for isolated night-time hypertension (K = 0.24), and was poor for office hypertension (K = 0.14). The better reproducibility of daytime than night-time period was confirmed by the analysis of BP as continuous variable (all between-period differences, P < 0.001). Nondipping was present in 31.8%, and showed a fair agreement (K = 0.28,). Poorer agreement was shown by extreme dipping (K = 0.18) and reverse dipping (K = 0.07). These data show that within the ambulatory sub-periods, daytime hypertension has a better reproducibility than night-time hypertension. This suggests that the better association with adverse outcomes shown by sleep BP compared to wake BP in observational studies is not due to a better reproducibility of the former. The between-measurement agreement is even worse for isolated nocturnal hypertension and dipping patterns, especially for extreme and reverse dipping. Thus, these BP phenotypes should be confirmed with repeat ambulatory BP monitoring.

Daytime actisensitivity predicts nocturnal dipping patterns and morning surge in blood pressure: the Home-Activity ICT-based Japan Ambulatory Blood Pressure Monitoring Prospective study.

Ambulatory blood pressure (BP) is influenced by physical activity and the BP response to physical activity (actisensitivity) differs between individuals. This study investigated associations between daytime actisensitivity and nighttime BP dipping status and morning BP surge. Twenty-four-hour ambulatory BP monitoring (ABPM) with simultaneously monitored physical activity using a multisensor all-in-one device (TM-2441; A&D Company) was performed at baseline in HI-JAMP study participants. Those with complete BP measurements and complete physical activity monitoring data were included in this analysis. Actisensitivity was calculated as the slope of the regression line between daytime SBP and log-transformed physical activity over a 5 min period before each BP reading. Hyper and negative reactivity were defined as actisensitivity greater than 90th and less than 10th percentile, respectively. Data from 2692 individuals (mean age 69.9 ± 11.9 years; mean BMI 24.8 ± 4.1 kg/m2, 53.6% men) were analyzed. Those with hyper reactivity had a high prevalence of the extreme dipper pattern of nighttime BP and exaggerated morning BP surge; those with negative reactivity had higher nighttime BP and a riser pattern of nighttime BP. Results remained significant after adjusting for 24-h physical activity. Differences in diurnal BP variability based on actisensitivity were augmented in individuals aged at least 75 years. This study is the first to investigate associations between actisensitivity and 24-h ambulatory BP profiles using an all-in-one multisensor device in a large real-world population. The associations seen between either hyper or negative actisensitivity and abnormal diurnal BP variability, especially in the elderly, could contribute to increased cardiovascular event risk. University Hospital Medical Information Network Clinical Trials Registry, UMIN000029151 (HI-JAMP study).

Assessment of blood pressure variability: characteristics and comparison of blood pressure measurement methods.

Previous studies have reported that blood pressure variability (BPV) is associated with the risk of cardiovascular events independent of blood pressure (BP) levels. While there is little evidence from intervention trials examining whether suppressing BPV is useful in preventing cardiovascular disease, it is suggested that detection of abnormally elevated BPV may be useful in reducing cardiovascular events adding by complementing management of appropriate BP levels. Cuffless BP devices can assess beat-to-beat BPV. Although cuffless BP monitoring devices have measurement accuracy issues that need to be resolved, this is an area of research where the evidence is accumulating rapidly, with many publications on beat-to-beat BPV over several decades. Ambulatory BP monitoring (ABPM) can assess 24-hour BPV and nocturnal dipping patterns. Day-to-day BPV and visit-to-visit BPV are assessed by self-measured BP monitoring at home and office BP measurement, respectively. 24 h, day-to-day, and visit-to-visit BPV have been reported to be associated with cardiovascular prognosis. Although there have been several studies comparing whether ABPM and self-measured BP monitoring at home is the superior measurement method of BPV, no strong evidence has been accumulated that indicates whether ABPM or self-measured home BP is superior. ABPM and self-measured BP monitoring have their own advantages and complement each other in the assessment of BPV.

Assessment of Nocturnal Blood Pressure: Importance of Determining the Time in Bed-A Pilot Study.

Objectives: Nocturnal blood pressure (BP) monitoring is essential for evaluating cardiovascular risk and guiding treatment decisions. However, the standardized narrow-fixed nighttime period between 10 p.m. and 6 a.m. may not accurately reflect individual sleep schedules. This pilot study aimed to investigate the comparability between the standardized nighttime period and actual time in bed (TIB) regarding BP assessment. Further, our goal was to evaluate the clinical relevance of the observed BP differences. Methods: A total of 30 participants underwent 24 h ambulatory blood pressure monitoring (ABPM). Patient-specific TIB was precisely assessed through an accelerometer and a position sensor from the SOMNOtouch NIBP™ (SOMNOmedics GmbH, Randersacker, Germany). We analysed the effect of considering individual TIB as nighttime instead of the conventional narrow-fixed interval on the resulting nocturnal BP levels and dipping patterns. Results: We observed differences in both systolic and diastolic BP between the standardized nighttime period and the TIB. Furthermore, a notable percentage of patients (27%) changed their dipping pattern classification as a function of the nighttime definition adopted. We found strong correlations between the start (r = 0.75, p < 0.01), as well as the duration (r = -0.42, p = 0.02) of TIB and the changes in dipping pattern classification. Conclusions: Definition of nocturnal period based on the individual TIB leads to clinically relevant changes of nocturnal BP and dipping pattern classifications. TIB is easily detected using a body position sensor and accelerometer. This approach may thus improve the accuracy of cardiovascular risk evaluation and enhance treatment strategies.

Obstructive sleep apnea and non-dipper: epiphenomena or risks of Alzheimer's disease?: a review from the HOPE Asia Network.

Obstructive sleep apnea (OSA) and associated nocturnal blood pressure (BP) surges is associated with non-dipper. On the other hand, the relationship between neurodegenerative diseases and non-dipper hypertension has been reported. To date, few studies have evaluated the relationships of nocturnal BP dipping patterns and OSA in relation to neurodegenerative diseases, particularly Alzheimer's disease (AD). This review examines the etiology of the association between OSA and the non-dipper pattern of hypertension and how both are involved in the development of AD. To set the stage for this review, we first focus on the pathophysiology of AD, which is interrelated with sleep apnea and non-dipper through dysregulation of central autonomic network.

5. Nocturnal Dipping Pattern in Hypertensive Patients as a Risk Factor for Cerebral Small Vessel Disease (CSVD): A Systematic Review and Meta-Analysis

Background: Cerebral small vascular disease (CSVD) is one of the most prevalent cerebral vascular pathologies encountered by middle-aged and older people, which can be observed by magnetic resonance imaging (MRI). The most important modifiable risk factor for CSVD is hypertension. Abnormal circadian blood pressure (BP) variability has been reported to significantly damage hypertensive patients’ target organs. Moreover, in many studies, controlling sleep blood pressure has been shown to exert greater protection against stroke and cardiovascular events. Objective: We aim to assess the nocturnal dipping pattern of blood pressure with the findings of cerebral small vessel disease. Method: We performed a comprehensive search on topics that assess nocturnal blood pressure monitoring and cerebral small vessel disease findings through imaging from inception up until November 2022. Result: There were a total of 2674 patients from 5 studies. The outcome of this study reported that reverse dipping and dipping BP patterns were significantly associated with the prevalence of CSVD. Meta-analysis showed that the reverse dipping BP pattern was associated with a higher risk for CSVD (OR 2.18 [1.80, 2.64], p = 0.64; I2: 0%, p &lt; 0.00001), meanwhile dipping pattern had a lower risk for CSVD (OR 0.51 [0.42, 0.63], p = 0.04; I2: 59%, p &lt; 0.00001). There was no association between the non-dipping pattern and CSVD (OR 0.92 [0.77, 1.10], p = 0.70; I2:0%, p = 0.35). Conclusion: Nocturnal BP pattern and CSVD were shown to be associated, with the reverse dipping BP pattern having a higher risk and dipping having a lower risk.

40. Nocturnal Hypertension and Dipping Pattern in Acute Stroke Patients

Background: In acute stroke patients, there is a well-known disruption of blood pressure patterns. The relationship between nocturnal hypertension as well as dipping patterns in acute stroke patients with neurological outcomes and recurrent stroke events is still being studied to create optimal blood pressure management.Until now, publications about blood pressure patterns in acute stroke patients are still limited. Objective: This article aims to describe events of nocturnal hypertension and dipping pattern in acute stroke patients. Method: We took secondary data from the use of an ambulatory blood pressure monitoring (ABPM) device for 24 hours that had been performed on acute stroke patients in the stroke unit dr. Cipto Mangunkusumo Hospital from October – December 2022. From the use of ABPM, the subject's blood pressure was grouped based on the dipping profile and the incidence of nocturnal hypertension. Result: A total of 9 subjects were included in the study, with median age 62 (49–75) years old, 66.7% had an ischemic stroke, and 33.3% hemorrhagic. Nocturnal hypertension was found in 77.8% among subjects who was meassured at onset #5 days, whereas in patients who were meassured at onset &gt;5 days, all had nocturnal hypertension. Nocturnal hypertension events did not occur in subjects without comorbid hypertension. Of all nine subjects, abnormal dipping patterns was found in 6 (66.7%) subjects (non-dipper 2 (22.2%), reverse dipper 3 (33.3%), and extreme dipper 1 (11.1%)). Conclusion: From this research, there is a high incidence of nocturnal hypertension and abnormal dipping pattern in acute stroke patients.

PS-P04-2: 24 HOUR AMBULATORY BLOOD PRESSURE PROFILE OF HYPERTENSIVE AND PRE-HYPERTENSIVE HEALTHCARE WORKERS IN A PHILIPPINE TERTIARY HOSPITAL

Objectives: To determine the blood pressure profile and phenotypes of hypertensive health care workers and its association to BP control dipping status. Design and Methods: This is a cross-sectional study of hypertensive employees who underwent 24 hr ambulatory blood pressure monitoring (ABPM). Clinical profile, and ABPM data were also evaluated Results: 181 patients were included with majority from 50–59 years old age group (33.3%), female (70.17%), non-shift workers (61.88%) with the most common comorbidity of obesity (60.22%) and suspected obstructive sleep apnea (60.22%). All the known hypertensives (100%) had uncontrolled blood pressure despite being on antihypertensive medication. The most frequent anti-hypertensive drug was an angiotensin receptor blocker (ARB, most cited was Losartan), comprising 62% among those on antihypertensive medication followed by calcium channel blockers (CCB- 23%). Majority or 73% were on mono therapy. The following hypertension phenotypes were identified: Sustained hypertension (64.7%), masked hypertension (13.26%), white coat hypertension (7.18%), and non-dippers (66%). Healthcare workers who work &gt; 9 hours were 2.05 times more likely to be non-dippers compared to healthcare workers who works up to 9 hours. Conclusion: Among health care workers, 24 hour blood pressure were uncontrolled more in females 50–59years old, with association on working hours&gt; 8 hours, without association to shift work, and job classification. There is a significant association of longer work hours and nocturnal dipping pattern. This study highlights the importance of 24-hour ABPM to detect 24-hr pattern and identify ABPM parameters at high risk for cardiovascular outcomes and finally determine blood pressure control among known hypertensive patients on maintenance medications.

PS-P03-7: 24 HR-AMBULATORY BLOOD PRESSURE PROFILE AND CLINICAL FEATURES OF HYPERTENSIVE AND PREHYPERTENSIVE HEALTH CARE WORKERS IN A PHILIPPINE TERTIARY CENTER

Background: Hypertension is a leading cause of cardiovascular morbidity, and its prevalence is increasing most rapidly in developing countries like the Philippines, where there is poor hypertension treatment and control ABPM is an important diagnostic tool among patients because it identifies hypertension phenotypes and circadian blood pressure profile that are known to be predictors for target organ damage and increased incidence of future cardiovascular event. Objectives: To determine the blood pressure profile and phenotypes of hypertensive and pre-hypertensive health care workers and its association to BP control and dipping status. Design and Methods: This is a cross-sectional study of hypertensive employees who underwent 24 hr ambulatory blood pressure monitoring (ABPM). Results: 181 patients were included with majority from 50–59 years old age group (33.3%), female (70.17%), non-shift workers (61.88%) with the most common comorbidity of obesity (60.22%) and suspected obstructive sleep apnea (60.22%). All the known hypertensives (100%) had uncontrolled blood pressure despite being on antihypertensive medication. The following hypertension phenotypes were identified: Sustained hypertension (64.7%), masked hypertension (13.26%), white coat hypertension (7.18%), and non-dippers (66%). Conclusion: There was high prevalence of sustained hypertension among healthcare workers included in this study. All those known hypertensives tested had uncontrolled blood pressure despite being on one or more antihypertensive therapy, while there were also newly diagnosed with masked hypertension. The overall prevalence of non-dippers and those with elevated mean 24- hour blood pressure levels was high, and there is significant association of working longer hours and nocturnal dipping pattern. However, there was no significant difference on nocturnal dipping status and blood pressure elevation among those with those with shift work, compared to usual office work hours. This study is one of the few local data on 24hr ambulatory blood pressure measurement of Filipino hypertensive and prehypertensive patients and is one of few data on use of ambulatory blood pressure monitoring among Asians. This also highlights the importance of 24-hour ABPM to identify ABPM parameters at high risk for cardiovascular outcomes and finally determine blood pressure control among known hypertensive patients according to the locally available maintenance medications.

JS-HR-7: BLOOD PRESSURE VARIABILITY; THERAPEUTIC TARGET FOR THE PREVENTION OF CARDIOVASCULAR DISEASE

In the past three decades, there have been many reports on the associations of various parameters of blood pressure (BP) variability with increased risk of cardiovascular disease (CVD) events; these parameters include short term BP variability (BPV), i.e., beat-by-beat BPV and ambulatory BPV, abnormality of nocturnal BP dipping pattern, and mid- to long-term BPV, i.e., day-by-day BPV, visit-to-visit BPV, and seasonal variations in BP. Several factors that are associated with abnormal BPV, as well as environmental factors such as cold or warm temperatures and seasonal changes in climate, increase fluctuations in BP. Individual intrinsic factors such as sympathetic nervous tone, arterial stiffness, physical activity, and mental stress also contribute to elevated BPV. According to evaluations of BPV abnormalities, out-of-office BP measurements such as ambulatory and home BP monitoring are needed. Although there are issues regarding measurement accuracy, cuffless BP monitoring devices, for example, those using pulse transit time, may be used to estimate nighttime BP levels. Such cuffless BP devices can also evaluate beat-by-beat BPV. Moreover, by using the multisensor-equipped ambulatory BP monitoring device developed by our research group, it is possible to evaluate BPV associated with changes in temperature, physical activity, and/or atmospheric pressure. Based on the mechanism(s) behind a given patients BPV abnormality, several methods may be considered for the management of that abnormality (Figure). For example, improving excessive sympathetic nervous system activation may be useful in the management of BPV abnormality, and renal denervation has been reported to decrease ambulatory BPV. Abnormal nocturnal BP dipping may be treated by decreasing nighttime BP. Moreover, early adjustment of antihypertensive drugs has been reported to be useful in suppressing seasonal variations in BP, leading to a decreased risk of CVD events. Furthermore, housing conditions and room temperature are closely related to BP levels, and adaptive control of room temperature would be useful to suppress winter increases in BP. In clinical practice, we must not forget that BPV parameters are interrelated. For instance, frequent evaluation of BP levels and adjustment of antihypertensive drugs can suppress visit-to-visit BPV, which in turn leads to the suppression of seasonal variations in BP. Over the next decade, greater data on how to manage and control BPV need to be accumulated. Additionally, future studies should be conducted to verify whether the different types of BVP management are useful in preventing CVD events.

Association between nocturnal blood pressure dipping and chronic kidney disease

Abstract Introduction Management of blood pressure (BP) in chronic kidney disease (CKD) is critical for preventing cardio-renal complications. While increasing attention has been given to discrepancies between office and ambulatory BP control in this population, information on nocturnal BP decrease patterns (dipping) in CKD is still scarce. Purpose We aimed at describing nocturnal BP dipping patterns and its predictors in patients with CKD. Methods We analysed data from patients with CKD stages 1 to 5 referred for kidney function testing from September 2006 to January 2022, including 24-hour urine collection, gold-standard measurement of glomerular filtration rate (GFR) using clearance of a radioisotopic tracer, as well as ambulatory BP measurement (ABPM) in a single tertiary hospital in Paris, France. A total of 1177 ABPM were available in 642 participants. The magnitude of dipping was calculated as the difference between day- and night-time systolic BP (SBP), in percentage of daytime SBP. Participants were then categorized as extreme-dippers (≥20%), dippers (10% to &amp;lt;20%), non-dippers (0% to &amp;lt;10%), or reverse-dippers (&amp;lt;0%). Factors associated with a less than 10% dipping were analysed with crude and adjusted logistic regression models including a random intercept to deal with clustering of measurements within patients. Results Participants (mean age 56±15 years; 35% female, mean GFR 49±21 mL/min per 1.73 m2) consisted of 8% extreme-dippers, 37% dippers, 40% non-dippers, and 15% reverse-dippers. The prevalence of non- or reverse-dipping increased with CKD severity, from 36% in CKD stage 1 to 65% in CKD stages 4–5 (Figure). In crude analyses, African origin, a lower measured GFR, a higher daytime SBP, diabetes, a higher number of antihypertensive medications and a higher 24-hour urinary sodium to potassium ratio (24h Na/K) were associated with abnormal dipping status. In the multivariable adjusted regression, non or reverse dipping was independently associated with measured GFR (odds ratio [OR, 95% confidence interval] per 10 ml/min/1.73 m2 decrease = 1.16 [1.06–1.26], p=0.001), daytime ambulatory SBP (OR per 10 mmHg decrease = 1.17 [1.06–1.28], p=0.001), African origin (OR= 1.56 [1.04–2.34], p=0.03) and 24h Na/K (OR per 1-unit increase = 1.20 [1.06–1.37], p=0.006). Conclusions The prevalence of nocturnal non-or reverse dipping BP profiles increases substantially across the spectrum of CKD. Measured GFR, ambulatory daytime SBP, African origin and 24-hour urinary sodium to potassium ratio are independent predictors of abnormal nocturnal BP decrease and thus may help in cardiovascular risk stratification in this population. More research is needed on whether nocturnal dipping may be a treatment target to reduce cardiorenal complications. Funding Acknowledgement Type of funding sources: None.

ABNORMAL DIPPING PATTERN OF NOCTURNAL BLOOD PRESSURE AS A PREDICTOR OF COGNITIVE IMPAIRMENT AND/OR DEMENTIA: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: Impact of abnormal nocturnal blood pressure (BP) dipping pattern on cognitive impairment and/or dementia is uncertain. The aim is to review the association between abnormal nocturnal BP dipping patterns (extreme dipping, non-dipping, or reverse dipping) and cognitive impairment and/or dementia in adults. Design and method: PubMed, MEDLINE, and EMBASE databases were systematically searched. Primary outcome was pooled odds ratios for cognitive impairment/dementia between normal and abnormal dipping patterns. Secondary outcomes were pooled mean Mini-Mental State Exam score among normal and abnormal dipping patterns, and pooled mean nocturnal dipping percentage among study participants with normal and low cognitive function. Results: When compared to normal dippers, reverse dippers have the strongest association with cognitive impairment/dementia (OR 5.56, 95%-CI 2.39–13.0, p = 0.0016) followed by non-dippers (OR 2.49, 95%-CI 1.39–4.45, p = 0.006). Association between extreme dippers and cognitive impairment/dementia was not statistically significant (OR 2.70 (95%-CI 0.80–9.12, p = 0.0904). The pooled mean Mini-Mental State Exam score among the non-dippers (26.8, 95%-CI 20.2 – 33.5) were lower than the normal dippers (27.4, 95%-CI 23.1–31.6). The standardized mean difference between the two groups was not significant (SMD -0.0694, 95%-CI -0.4998–0.361, p = 0.677). The pooled mean nocturnal dipping percentage among study participants with low cognitive function was (8.24%, 95%-CI 5.21–11.3) less than study participants with normal cognitive function (11.5%, 95%-CI 8.83–14.1). Similarly, the standard mean difference of mean nocturnal dipping percentage between the two groups was not significant (SMD -0.934, 95%-CI -2.053–0.186, p = 0.0906). Conclusions: Abnormal nocturnal dipping pattern may be a risk factor for cognitive impairment/dementia. Multiple included studies with cross-sectional data sets precludes drawing valid causal inference between dipping pattern and cognitive impairment.

PREVALENCE AND PREDICTORS OF NOCTURNAL BLOOD PRESSURE DIPPING IN CHRONIC KIDNEY DISEASE

Objective: Management of blood pressure (BP) in chronic kidney disease (CKD) is critical for preventing cardio-renal complications. Information on nocturnal BP decrease patterns (dipping) in CKD is still scarce. We aimed at describing nocturnal BP dipping patterns and its predictors in patients with CKD. Design and method: We analysed data from patients with CKD stages 1 to 5 referred for kidney function testing from September 2006 to January 2022, including 24-hour urine collection, gold-standard measurement of glomerular filtration rate (GFR) using clearance of a radioisotopic tracer, as well as ambulatory BP measurement (ABPM) in a single tertiary hospital in Paris, France. A total of 1177 ABPM were available in 642 participants. The magnitude of dipping was calculated as the difference between day- and night-time systolic BP (SBP), in percentage of daytime SBP. Factors associated with a less than 10% dipping were analysed with adjusted logistic regression models including a random intercept to deal with clustering of measurements within patients. Results: Participants (mean age 56 ± 15 years; 35% female, mean GFR 49 ± 21 mL/min per 1.73 m2) consisted of 8% extreme-dippers (&gt; = 20%), 37% dippers (10% to &lt; 20%), 40% non-dippers (0% to &lt; 10%), and 15% reverse-dippers (&lt;0%). The prevalence of non- or reverse- dipping increased with CKD severity, from 36% in CKD stage 1 to 65% in CKD stages 4–5 (Figure). Non or reverse dipping was independently associated with measured GFR (odds ratio [OR, 95% confidence interval] per 10 ml/min/1.73m2 decrease = 1.16 [1.06 – 1.26], p = 0.001), daytime ambulatory SBP (OR per 10 mmHg decrease = 1.17 [1.06–1.28], p = 0.001), African origin (OR = 1.56 [1.04 – 2.34], p = 0.03) and 24 h Na/K (OR per 1-unit increase = 1.20 [1.06 – 1.37], p = 0.006). Conclusions: The prevalence of nocturnal non-or reverse dipping BP profiles increases substantially across the spectrum of CKD. Measured GFR, African origin, ambulatory daytime SBP and 24-hour urinary sodium to potassium ratio are independent predictors of abnormal nocturnal BP decrease and thus may help in cardiovascular risk stratification in this population. More research is needed on whether nocturnal dipping may be a treatment target to reduce cardiorenal complications.

NOCTURNAL DIPPING PATTERN IN 24-HOUR AMBULATORY BLOOD PRESSURE RECORDINGS OF HYPERTENSIVE INDIVIDUALS IN THE BAY OF PLENTY (BOP)

Objective: 24-Hour Ambulatory blood pressure monitoring (ABPM) is gold standard for diagnosis/management of hypertension (HT). Untreated and poorly controlled HT leads to increased rates of cerebrovascular, cardiovascular, and renal disease. Data is lacking on dipping patterns in different ethnicities of New Zealand (NZ). The primary aim was to compare nocturnal dipping pattern between Maori and Non-Maori ethnicities. Secondary aims included comparison of nocturnal HT, morning surge index (MSI) and ambulatory arterial stiffness index (AASI) amongst them and comparison as per socio-economic deprivation index (NZDep 2018). Design and method: ABPM data of hypertensive adults &gt; 18 years of age (on antihypertensives) in EBOP was collected retrospectively from Midland Clinical Portal from 1st December 2018 to 31st July 2021. Duplicates or unsuccessful ABPM results were excluded from the analysis. Normal dipping was defined as 10–20%, non-dipping being 0- &lt; 10%, reverse dipping &lt; 0% and extreme dipping &gt; 20%. Statistics were processed using Excel. Results: Of 213 ABPMs nalysed, 20% were of Maori individuals. 39.5% of Maori were non-dippers and 9.3% were reverse dippers. Amongst Non-Maori, 34.1% were non-dippers and 13.5% were reverse dippers (p = 0.840). Uncontrolled nocturnal HT was more likely in Maori (60.5%) as compared to Non-Maori (54.1%), though not significant (p = 0.454). AASI was significantly higher (p = 0.001) in Non-Maoris, though MSI was not different (p = 0.865). Lower socio-economic demographic individuals or Maori are less likely to receive ABPM. Conclusions: There was no statistical difference between dipping status of Maori and Non-Maori. However, it is evident up to 55% of patients in this data set have uncontrolled nocturnal HT suggesting that EBOP is receiving subtherapeutic management of their HT. Therefore, all hypertensives should have ABPM in NZ to manage HT. As HT is more prevalent in Maori, researchers recommend a commitment from Bay of Plenty District Health Board to address this inequity to improve cardiac, cerebrovascular and renal health.

Loss of nocturnal dipping pattern of skin sympathetic nerve activity during and following an extended-duration work shift in residents in training

BackgroundExtended-duration work shifts (EDWSs) might affect the health of physician residents, causing autonomic alteration. Skin sympathetic nerve activity (SKNA) recorded by noninvasive neuro-electrocardiography (neuECG) is used to estimate cardiac sympathetic tone. In this study, we aim to evaluate the impact of EDWSs on nocturnal SKNA assessed in resident doctors. MethodsTwenty-four residents working EDWSs and 12 PhD students not working nightshift schedules were prospectively recruited. The neuECG was performed between 12 am and 6 am for 5 consecutive nights. SKNA was filtered from neuECG recorded signals. The questionnaires regarding work stress and sleep quality, blood pressure, and salivary alpha-amylase and cortisol levels were administered. ResultsThe hours of weekly working and sleep opportunities were similar between residents and students, while residents reported more work stress and worse sleep quality. In residents, SKNA at 6 am (SKNA6am) was significantly higher than SKNA2am during the precall night, revealing a dipping pattern. However, the SKNA dipping disappeared during the on-call night and prominently flattened during the first postcall night, the full recovery of which was delayed until the second postcall nights. The morning blood pressure and salivary alpha-amylase and cortisol levels were similar between the precall and postcall days. In contrast, SKNA in students exhibited a constant dipping profile for all recorded nights. ConclusionsIn healthy young adults, SKNA presents a dip night. The SKNA dip is impaired by working a nightshift, with a delayed recovery. The neuECG might serve as a useful tool to detect subclinical autonomic disturbances in shiftworkers.

Determinants of reverse dipping blood pressure in normotensive, non-diabetic population with an office measurement below 130/85mmHg

ABSTRACT Objective: The role of dipping blood pressure pattern in normotensives is unclear. The study aims to search the circadian blood pressure rhythm and the clinical determinants related to reverse dipping pattern in a strictly selected, normotensive population. Methods: The study population was divided into three groups depending on the nocturnal dipping pattern as dipping, non-dipping, and reverse dipping. Basal clinical characteristics, anthropometric measurements, and spot urine samples from the first-morning void were collected. Clinical determinants related to the presence of reverse dipping pattern were tested by the Multiple Binary Logistic Regression analysis. Results: A total of 233 participants were involved in the study population (median age 45 years [40–50]). Dipping pattern was detected in 55.4%, non-dipping pattern in 33.0%, and reverse dipping pattern in 11.6% of the study population. There was no difference between the groups in terms of basal clinical features. Albumin-to-creatinine ratio (ACR) (p < .001) and hs-CRP levels (p = .006) were also statistically significant across the groups. ACR (HR: 1.195, 95% CI: 1.067–1.338, p = .002) and hs-CRP (HR: 2.438, 95% CI: 1.023–5.808, p = .044) were found to be related to the presence of reverse dipping blood pressure pattern. Conclusions: The absence of nocturnal physiological dipping is seen at a remarkable rate in the normotensive Turkish population. ACR and hs-CRP are the clinical determinants related to the presence of reverse dipping blood pressure pattern.

Circadian blood pressure profile and blood pressure changes following oral appliance therapy for obstructive sleep apnoea.

Oral appliance therapy for obstructive sleep apnoea (OSA) reduces blood pressure (BP) but there is little information on relationship to circadian BP pattern (nocturnal BP dipping or non-dipping). The aims of this study were to determine whether nocturnal dipping pattern influences BP changes following oral appliance therapy, and to determine the effect of oral appliance therapy on circadian BP pattern. Participants in two randomized trials of oral appliance therapy (1-2 months) with 24-h ambulatory BP monitoring (ABPM) data were included (N = 152). Nocturnal BP Dippers (nocturnal/diurnal SBP ratio <0.9) and non-dippers were compared for BP changes following oral appliance therapy and the effect of oral appliance therapy on nocturnal BP dipping was assessed. Of 152 participants, 64.5% were dippers. Dippers were on average younger and less likely to be hypertensive (42 vs. 82.7%, P < 0.001). Nondippers showed greater reduction in nocturnal BP measures, related to higher BP measures at baseline. There was no difference in the relationship between treatment effectiveness and BP changes between groups. Oral appliance therapy converted only 23% of baseline non-dippers to a nocturnal dipping profile. Baseline circadian BP profile influenced the BP response to oral appliance therapy, largely because of higher baseline BP in the non-dipper subgroup. Oral appliance therapy did not convert OSA patients to a more favourable circadian BP profile. Further work is required to understand the effect of oral appliance therapy on circadian BP profile and of the individuals who will receive cardiovascular benefit from oral appliance therapy.

8. ASSOCIATION OF NOCTURNAL BLOOD PRESSURE DIPPING PATTERN WITH CARDIOVASCULAR EVENTS AND ALL-CAUSE MORTALITY IN PATIENTS WITH HYPERTENSION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background: Hypertension remains a main contributor to morbidity and mortality worldwide. Studies have found that ambulatory blood pressure (BP) monitoring is superior to clinic BP in predicting prognosis in patients with hypertension. Assessment of nocturnal BP dipping pattern during ambulatory BP monitoring can provide additional prognostic significance and guide treatment decisions. Objective: To conduct a systematic review and meta-analysis of the association of nocturnal BP dipping pattern with cardiovascular events and all-cause mortality in patients with hypertension. Methods: Relevant literature was identified using PubMed, ProQuest, Cochrane Library, Embase, and Google Scholar. Subjects were categorized as dippers or non-dippers according to systolic dipping pattern by ambulatory BP monitoring. Dippers was defined as decreased in systolic BP from day to night of ≥10%. Non-dippers was defined as decreased in systolic BP from day to night of &lt;10%. The outcomes were cardiovascular events and all-cause mortality. Meta analysis was performed using Review Manager 5.3 software. Results: Eight cohort studies involving a total of 5260 hypertensive patients were included, of which 6 studies reported data on cardiovascular events and 4 studies reported data on all-cause mortality. On pooled analysis, hypertensive patients classified as non-dippers had significant increased risk of cardiovascular events compared with dippers (risk ratio [RR] 1.82; 95% confidence interval [CI] 1.55–2.14; p &lt; 0.00001; I 2 = 50%). Similarly, non-dippers had significant increased risk of all-cause mortality compared with dippers (RR 2.49; 95% CI 1.82–3.41; p &lt; 0.00001; I 2 = 10%). Conclusion: In patients with hypertension, the non-dipper pattern was significantly associated with increased risk of cardiovascular events and all-cause mortality.

Capillary vascular density in the retina of hypertensive patients is associated with a non-dipping pattern independent of mean ambulatory blood pressure.

A nocturnal non-dipping pattern has been associated with hypertension-mediated organ damage (HMOD), morbidity and mortality. Retinal imaging through application of modern technologies including optical coherence tomography angiography (OCT-A) can provide detailed insights into early vascular damage. In this observational study, we investigated the relationship of microscopic vascular density in the retina measured with OCT-A and nocturnal blood pressure (BP) dipping. Retinal OCT-A and ambulatory BP monitoring (ABPM) data prospectively obtained from 142 patients referred to a tertiary hypertension clinic were analysed with regression models for associations between BP night-time dipping and retinal capillary vascular density in three different zones around the fovea. More pronounced nocturnal SBP and DBP dipping was significantly associated with increased vascular density in the central foveal area of the retina. These associations were robust to adjustment for other available risk factors including mean daytime BP. Parafoveal and whole image vascular density did not show equivalent significant associations with nocturnal BP dipping. The results were reproducible when assessed in a subgroup of patients who had concomitant type 2 diabetes. Foveal vascular density was associated with the nocturnal BP dipping pattern in hypertensive patients. These associations were robust to adjustment of relevant factors such as daytime BP. Our findings highlight the importance of nocturnal BP features reflected in ambulatory BP monitoring in the assessment of HMOD. Whether routine assessment of retinal damage markers may improve risk management of hypertensive patients remains to be determined.